Nursing Skin, Fluid, Electrolyte, and Acid-Base Assessment Quiz

What are the three layers of skin?

Epidermis, dermis, subcutaneous

What is the most significant risk factor for skin breakdown?

Immobility

What assessment tool predicts pressure injury risk?

Braden Scale

A butterfly rash is associated with what disease?

Lupus

What are diabetics at increased risk for?

Ulcers

Why are heating pads dangerous for diabetics?

Decreased sensation increases burn risk

Non-blanchable redness over a bony prominence indicates?

Stage 1 pressure injury

Partial-thickness skin loss indicates?

Stage 2 pressure injury

Visible fat tissue indicates?

Stage 3 pressure injury

Exposed bone or muscle indicates?

Stage 4 pressure injury

What does serous drainage look like?

Clear, watery

What does sanguineous drainage look like?

Bloody red

What does purulent drainage indicate?

Infection

What is fluid volume deficit?

Loss of fluid from extracellular space

Signs of fluid volume deficit?

Tachycardia, hypotension, dry mucous membranes

Signs of fluid volume excess?

Edema, crackles, JVD

What is the best indicator of fluid balance?

Daily weight

What IV solution is isotonic?

0.9% Normal Saline

What IV solution is hypotonic?

0.45% Normal Saline

What IV solution is hypertonic?

3% Normal Saline

Hypertonic fluids move water:

Out of cells

Hypotonic fluids move water:

Into cells

Who should not receive hypotonic fluids?

Patients with increased intracranial pressure

Signs of IV fluid overload?

Crackles, edema, JVD, bounding pulse

First action for fluid overload?

Slow/stop IV and notify provider

Normal sodium?

135-145

Hyponatremia means sodium:

Less than 135

Hypernatremia means sodium:

Greater than 145

Hyponatremia causes water to move:

Into cells

Hypernatremia causes water to move:

Out of cells

Normal potassium?

3.5-5.0

Hypokalemia means potassium:

Less than 3.5

Hyperkalemia means potassium:

Greater than 5.0

Priority assessment for hyperkalemia?

ECG

ECG change in hyperkalemia?

Peaked T waves

ECG change in hypokalemia?

Flattened T waves

Why is potassium important?

Cardiac function

Signs of hypocalcemia?

Tetany, numbness, tingling

Signs of hypercalcemia?

Muscle weakness

Signs of hypomagnesemia?

Tremors, seizures

Signs of hypermagnesemia?

Respiratory depression, decreased reflexes

Normal pH?

7.35-7.45

pH 7.25 indicates?

Acidosis

pH 7.50 indicates?

Alkalosis

ROME stands for?

Respiratory Opposite, Metabolic Equal

Prolonged diarrhea causes?

Metabolic acidosis

Kussmaul respirations are associated with?

Metabolic acidosis

Patient receiving opioids is at risk for?

Respiratory acidosis

Signs of metabolic alkalosis?

Tetany, hyperreflexia, numbness/tingling

If a blood transfusion reaction occurs, what is the FIRST action?

Stop the transfusion immediately